Monday, December 22, 2014

On December 23, 2009, the day before the United States Senate passed its version of what later became known as Obamacare, I posted a rhyme comparing the debate to Dr. Seuss’ famous tale about the Grinch who (tried) to steal Christmas, with the GOP in the role of the “Grinch” and Obamacare playing the part of Christmas. Here’s my updated version—all intended to be in good (non-partisan) fun!

Every Dem
In the Congress
Liked Obamacare, a lot ...

But the GOP
Who sat to their right,
Did NOT!

The GOP hated ObamaCare! (Some called it treason)!
Now, please don't ask why. No one quite knows the reason.
It could be their base is far to the right.
It could be, perhaps, that money is tight,
But I think that the most likely reason of all
Is Republicans like their government, small.

But,
Whatever the reason,
Their base or their views,
They stood there on Christmas Eve, hating it all,
Staring down with a sour, disapproving frown
They vowed that next year, they’d bring it all down.

"We’ll control the House, and the Senate!" they snarled with a sneer.
"Our chance for repeal is coming! It's practically here!"
Then they growled, with their fingers nervously drumming,
And said, “Obamacare’s demise is finally coming!"
For, in 2015, they knew...

...They would finally be freed
Of having to get things past old Harry Reid,
With Mitch in charge, they’d slay the Obamacare beast.
And then they'd feast! And they'd feast!
And they'd FEAST! FEAST! FEAST! FEAST!
Because “socialized” medicine, you know, they can’t stand in the least!

And the more they thought of finally prevailing,
They started to worry, about possibly failing.
Obama can veto our plans, strike them all down
We can’t let him let him stop repeal from coming!
... But HOW?"

Then they got an idea!
An awful idea!
THE GOP
GOT A WONDERFUL, AWFUL IDEA!

"We know just what to do!" They laughed in their throat.
“We just need the Supremes to strike it down, on a 5 to 4 vote!"
And they chuckled, and clucked, "What a great GOP fix!
We'll sue Obama and let the court do the trick!

"We’ll say that Congress never planned for the subsidies to apply,
In the GOP states that want Obamacare defied,
Who cares about the facts, or legislative intent?
As long as we can persuade five judges to relent
And strike the subsidies down, for better or worse,
We can get it tossed out, chapter and verse.

"Pooh-pooh to Obama!" they were heard to be humming.
"By June he’ll find that the end is finally coming!
When the court rules against him! We know just what he’ll do!
His mouth will stay open a minute or two
And Barack Obama will cry BOO-HOO!

"That's a noise," grinned the GOP,
"That we simply must hear!"
So they paused. And the GOP put a hand to their ears.

And they did hear a sound rising over DC town.
It started out low, and then got quite loud,
But the sound they heard from the White House wasn't sad!
Why, this sound sounded merry!
It couldn't be so!
But it WAS merry! VERY!

They stared down at the Washington Post headline
And the GOP popped their eyes!
Then they shook! And they shook,
What it said was such a surprise!

On a five to 4 vote, the Roberts Court
Again upheld Obamacare, made their case naught,
They HADN’T stopped ObamaCare from coming!
IT CAME!
Somehow or other, it came just the same!

And the GOP, even with all of the Koch brothers’ dough,
Kept puzzling and puzzling: How could it be so?
Obamacare came despite our winning the midterm election!
It came though the pundits said it was an Obamacare rejection!
It came even despite the demands of Senator Cruz,
It came despite the ranting by our friends at Fox News,
They puzzled three hours, ‘till their puzzler was sore.
Then they thought of something they hadn’t before!
“Maybe ObamaCare,” they thought, “means something more.
Maybe it really is about getting healthcare to the millions of poor.”

And what happened then…?
Well … in Washington they say
That the GOP took heart
And vowed to fight on anyway!
“We can still kill the law, if we just do it right,
We’ll do it in through reconciliation, we’ll continue this fight
As we promised the Tea Party, who like Obama the least
…WE OURSELVES …!
Won’t rest until we carve up the ObamaCare beast!”

Of course, one part of my rhyme--the Supreme Court upholding Obamacare’s premium subsidies--assumes that this will be the outcome of case that the court has agreed to hear, challenging the legality of the subsidies in the 36 states that opted to let the federal government run their health insurance exchange. In fact, we really won’t know the outcome until the Court issues its ruling (likely in June, 2015). Let’s hope that the Supreme Court upholds the subsidies—because if they don’t, millions of Americans would lose their health insurance coverage. And that would truly be a reason to cry Boo-Hoo!

Today’s question: No question, just my best wishes to you for a happy holiday season and prosperous and healthy New Year. (P.S., This will be my final blog post of 2014, will be back in early 2015).

Wednesday, December 17, 2014

As of 11 a.m. this morning, because of readers like you, this blog has received 2,001,555 lifetime page views! (A page view represents each time a visitor views a page on a website). The lifetime of this blog began on October 29, 2008, when I asked, 'Is healthcare a privilege, a right, or a responsibility?' This inaugural post generated a spirited debate among the 11 people who posted comments in response. (We as a society are still debating this question, although the Affordable Care Act clearly shifted public policy toward establishing healthcare as a right, over the continuing fierce objections of its conservative critics). This is my 465th post; collectively, the posts to date have received 2178 published comments.

I accompanied this first post with a description of myself and what I hoped to achieve through the ACP Advocate blog:

This blog will reflect my work with ACP, but will not be a mouthpiece for ACP's positions. Instead, I hope to invite commentary on the most provocative and intriguing health policy discussions I come across in my daily work.

This continues to be my goal.

Which of my posts generated the greatest interest, as measured by page views, from you, the readers? Here are the top 5:

1. My April 25, 2014, post, Yes, times are tough, but don’t compare doctors to janitors, in which I challenged a comparison made by blogger Daniela Drake, received the most page views, by far.

2. Next was my November 5, 2014 post, What does the 2014 election mean for Obamacare?3. My March 28, 2012 post, Don’t Ask, Don’t Tell, in which I criticized laws that restrict physicians’ ability to discuss firearms and other medically-appropriate health issues with their patients, was next.

4. On January 15, 2014, in What my auto accident taught me about Obamacare, I wrote about my own very personal experience of a car crash. I wrote that I was fortunate: my injuries were limited to a fractured sternum and my pride (I inexplicably drove my car into a tree). But the accident also taught me that we are all vulnerable and how important having health insurance is; What might have been the outcome for someone in the same circumstances as me, but without health insurance and with a much more modest income? And I was reminded of how government regulation (in this case, air bags) helped keep me from suffering worse injuries. This post topped the all-time list with the number of comments (25) posted in reply.

5. Next was my December 17, 2013 post, What Physicians Should Expect When the ACA goes live on January 1.

Interestingly, although the vast majority of page views for the ACP Advocate blog are from within the United States, there is a significant international audience for it:

Because of the visibility created by this blog, I have also become a periodic guest blogger for the Philadelphia Inquirer, where on Monday of this week I posted The Collapse of the Case Against Obamacare, citing data that most of the critics’ dire predictions have not come to pass. And the www.KevinMD.com blog often reposts my ACP Advocate blogs, most recentlyObamacare, The Anti-Death Panel Law.

I realize that this post might come across as self-promotional (although this is inherent in social media, which measures its relevance by page views, hits, retweets, mentions, and a whole host of other statistics that try to measure, 'Who is paying attention to what I have to say?').

But my real point in writing this is to thank you, the readers of this blog; whether you post comments or not, you are helping to stimulate a conversation “about the most provocative and intriguing health policy discussions I come across in my daily work,” as I promised on October 29, 2008. But I especially want to thank those of you who do take the time to post your comments. Now you know that your views may be reaching the numerous visitors to the ACP Advocate blog!

Today’s question: What would you recommend to make the ACP Advocate blog more relevant to you, and others, and to increase the number of views and comments?

Friday, December 12, 2014

The 113th Congress will be wrapping up its two year session within the next few days—and good riddance! Measured by how many laws it is has passed, this Congress is likely to turn out to be the least productive in modern U.S. history.

Now, some might say that passing laws isn't necessarily a good thing, if it results in bad laws. The problem, though, is that because this Congress was unable to reach agreement on just about everything and anything, many important issues where legislation is needed were neglected.

Take two of the medical profession’s highest priorities: repeal of the Medicare SGR formula, and continuation of a program that raised Medicaid payments to primary care physicians (and related subspecialists) to no less than the Medicare rates. Despite the best effort made by ACP, and many others, Congress failed to complete action on either. This is how I explained the situation in an email I sent yesterday to the 12,000-plus internists who participate in the College’s grassroots ACP Advocates network:

Dear ACP Advocates,

I am writing to thank you for all of the work you have done to help ACP advance its advocacy agenda with the 113th Congress, and to update you on where things stand on two of our highest priorities: (1) reform of the Medicare physician payment system and repeal of the SGR formula, and (2) continuation of the Medicaid primary care pay parity program. I also write to share with you our current thinking about priorities for the new 114th Congress, which will take office in January.

Historians are likely to label the 113th Congress as perhaps the least productive ever, as it has compiled an unprecedented record of failing to address the key challenges facing our country. Regrettably, improving healthcare will be among the many issues where Congress has failed to act.

Specifically, it is now evident that Congress will, within a few days, adjourn without enacting legislation to repeal the Medicare SGR formula or to reauthorize the Medicaid primary care pay parity program.
This is not the first time that Congress has failed to enact legislation to repeal the Medicare SGR formula, of course, but it is particularly frustrating this time around, because Congress was so close to enacting a bipartisan and bicameral (House and Senate) bill to permanently repeal the SGR and make other improvements in Medicare payment policies. You may recall that both parties had agreed to such a bill earlier this year, but they couldn’t agree on how to pay for it. So, instead, they passed another temporary “patch” to prevent an SGR payment cut that would have gone into effect on April 1—their 17th patch over the past 11 years! This patch will expire on March 31, 2015, at which time the SGR is scheduled to cut physician payments by another 21 percent.

Even so, despite the patch, ACP did not give up on getting full SGR repeal in the 113th Congress. With your support, ACP has continued to press Congress to enact the bicameral and bipartisan SGR repeal bill in the current post-election “lame duck” session. We now know, though, that they will end the year without doing so, to our great disappointment.This does not mean, though, that your and our advocacy on SGR repeal has been for naught. Because of our efforts, ACP was able to influence this bipartisan, bicameral SGR repeal bill to include positive payment incentives for physicians who practice in a Patient-Centered Medical Home; to simplify and harmonize Medicare reporting programs (including removing scheduled penalties under those programs); and to make many other improvements. We fully expect that this bill will be the starting point for the new 114th Congress next year, and we will redouble our efforts to get Congress to act upon it before the current patch expires on March 31.Similarly, this Congress’s failure to reauthorize the Medicaid primary care pay parity program is not the end of the story. Because Congress did not reauthorize this program--which pays internists (including our subspecialists) no less than the Medicare rates for designated services to Medicaid enrollees--most of you will see deep cuts in your Medicaid primary care payments on January 1. ACP will continue its efforts to inform the new 114th Congress of the devastating impact such cuts will have on Medicaid patients’ access to primary care, and to seek to get Medicaid pay parity renewed early in the new Congress. We also will work with our chapters to explore opportunities to get the program funded by the states.
I am sure you are disappointed, even angered, by Congress failing to complete action on these two top ACP priorities, as we are. Earlier today, ACP issued a public statement expressing “profound” disappointment with Congress’ inaction on the SGR and Medicaid pay parity. But this is not the time for us to throw in the towel. Next year, ACP’s congressional advocacy agenda will include not only SGR repeal and reauthorization of Medicaid pay parity, but also, reauthorization of the current Medicare 10 percent primary care bonus program, which expires at the end of 2015; reform of Graduate Medical Education financing; medical liability reform; regulatory relief from meaningful use requirements, and much, much more. You, as a member of our over 12,000-strong ACP Advocate grass roots network, will be critical to our efforts in the new 114th Congress.

There is not much more that I can say in this space, other than to say how Congress’s inability to agree on policies to improve Medicare and Medicaid payments is simply maddening to me, my colleagues on the ACP advocacy staff, and the ACP leadership, as I expect it is for most readers of this blog.

Yet we remain fully determined to try to move both issues, and other ACP priorities, forward in the new 114th Congress.

Today’s questions: What do you think of the record of the “least productive Congress ever” on healthcare, including the SGR and Medicaid primary care pay parity? Do you expect things to be better with the new Congress?

Thursday, December 11, 2014

One of the findings included in a Senate investigative committee’s report on the US government’s post-9/11 torture program was that it was designed by two psychologists. They were paid “$80 million to develop torture tactics that were used against suspected terrorists in the wake of the September 11 attacks on the Pentagon and the World Trade Center”—including “waterboarding and mock burial on some of the CIA’s most significant detainees.” (This isn’t the first time that the involvement of these two psychologists has been made public, but the new report provides more detail on their role—and the methods used).

The idea that a healthcare professional designed—and reportedly, personally helped administer—the torture of detainees would appear to me to be an appalling violation of professional ethics.

In 2009, I wrote in this blog about the ACP’s efforts to pressure the U.S. government to prohibit torture of detainees. I noted then that the College’s ethics manual clearly states that:

"Physicians must not be a party to and must speak out against torture or other abuses of human rights ... Under no circumstances is it ethical for a physician to be used as an instrument of government to weaken the physical or mental resistance of a human being, nor should a physician participate in or tolerate cruel or unusual punishment or disciplinary activities beyond those permitted by the United Nations Standard Minimum Rules for the Treatment of Prisoners ... Interrogation is defined as a systematic effort to procure information useful to the purposes of the interrogator by direct questioning of a person under the control of the questioner. Interrogation is distinct from questioning to assess the medical condition or mental status of an individual."

I also reported that, in 2003, ACP wrote to then-President George W. Bush to urge his administration to investigate allegations that the U.S. may have engaged in unlawful interrogations including torture, and again, in a follow up letter dated May 17, 2004. This is what the White House told us in response:

“As the President has said, Americans stand against and will not tolerate torture. American personnel are required to comply with all applicable United States laws, including the Constitution, Federal Statutes, and our treaty obligations with respect to treatment of detainees ... The United States will continue to take seriously the need to question terrorists who have information that can save lives, but will not compromise the rule of law or the value and principles that make our country strong. Torture is wrong no matter where it occurs, and under President Bush's leadership, the United States will continue to lead the fight to eliminate it everywhere."

We now know from the Senate report that the White House response to us does not square with the facts.

I am proud of the ACP’s role in speaking out against torture, which also included introducing a resolution to the AMA House of Delegates, and supporting an amendment by Senator John McCain to codify a ban on torture. And, on March 3 of 2009, we joined with the American Psychiatric Association to support President Obama’s executive order banning torture.

But it is disheartening to find that despite our efforts, torture was used against prisoners detained by the U.S. government, and that the program itself was designed by mental health professionals. Yes, it is true that they were psychologists, not MDs or DOs, so arguably, they are not governed by the ACP’s code of ethics, or that of the American Psychiatric Association.

But they should have been expected to honor the American Psychological Association’s standards of ethics, which clearly states that “Any direct or indirect participation in any act of torture or other forms of cruel, degrading or inhuman treatment or punishment by psychologists is strictly prohibited. There are no exceptions. Such acts as waterboarding, sexual humiliation, stress positions and exploitation of phobias are clear violations of APA's no torture/no abuse policy.”

Moreover, the psychologists’ association has just released a statement on the Senate report, in which it states that “two psychologists mentioned prominently in the report under pseudonyms, but identified in media reports as James Mitchell and Bruce Jessen, are not members of the American Psychological Association. Jessen was never a member; Mitchell resigned in 2006. Therefore, they are outside the reach of the association’s ethics adjudication process. Regardless of their membership status with APA, if the descriptions of their actions are accurate, they should be held fully accountable for violations of human rights and U.S. and international law.”

Good for them! The question is, will these psychologists be able to keep their licenses? Will they be held accountable for violations of human rights and U.S. and international law?

Today’s questions: What is your reaction to the report on the U.S. torture program? Are physicians and other health professionals doing enough to speak out against torture? And what do you think should be done to hold the two psychologists involved accountable for their actions?

Thursday, December 4, 2014

One of the most pernicious lies about Obamacare is that it establishes “death panels” to ration needed care, especially care of seniors. Although thoroughly discredited by independent fact checking sites, the death panel falsehood remains a staple of attacks on the Affordable Care Act.

But it isn’t just that Obamacare doesn’t have death panels or anything remotely like them (the law actually prohibits denying benefits based on cost); we now have strong evidence that the law is actually saving lives, and particularly, the lives of seniors.

Earlier this week, the Department of Health and Human Services released a report that shows “an estimated 50,000 fewer patients died in hospitals and approximately $12 billion in health care costs were saved as a result of a reduction in hospital-acquired conditions from 2010 to 2013” and another 15,000 lives may have been saved by preventing unnecessary hospital readmissions.

These life-saving improvements didn’t just magically happen of their own accord, but are directly associated with two Obamacare programs:

The Partnership with Patients is a collaboration of federal agencies, hospitals, physicians, patients and families to design and implement best practices to reduce health facility acquired infections. The Partnership with Patients, notes Sarah Kliff, a former Washington Post reporter who is now with Vox Media, is “a government project that's part of the Affordable Care Act, aiming to reduce the number of hospital-acquired conditions by 40 percent between 2010 and 2014. That program has enrolled more than 3,700 hospitals — who account for four in every five hospital patients — in a learning collaborative to share best practices for increasing patient safety.”

The Readmissions Reduction Program, created by Section 3025 of the Affordable Care, requires CMS to reduce payments to hospitals with excess readmissions, effective for discharges beginning on October 1, 2012. Following implementation of this program, “The readmission rate for patients who receive care under the traditional Medicare fee-for-service program, “which held steady at 19 percent from 2007 to 2011 — fell to 18.5 percent in 2012 and 17.5 percent in 2013” writes Sarah Kliff. “The 1.5-percentage-point decrease in readmissions accounts for 150,000 fewer patients readmitted to a hospital when they didn't need to be.”

So instead of allowing the critics to scare seniors about non-existent death panels, we need to spread the word that Obamacare is really the anti-death panel law, helping to make health care better and safer for millions.

Today’s question: What do you think about the reductions in hospital infections and readmissions attributable to Obamacare?